Home Health RN Case Manager - Newburyport Area

Tufts Medicine • Newburyport, MA

7d • $84,300 - $107,481

About The Position

The Home Health Registered Nurse uses the nursing process to manage and deliver comprehensive home health services to clients in their residences, including assessments, interventions, and supportive care. Depending on circumstances, the role may include telephone triage, problem solving, and patient and caregiver advocacy and support, with an emphasis on avoiding hospitalization.

As a member of the health care team, the nurse interacts courteously and effectively with patients and their families, agency colleagues, community resources, and patients’ physicians to facilitate safe and efficient care. The role requires maintaining personal safety in the home and broader community. The nurse manages an assigned caseload, independently plans and prioritizes daily work, and may provide rotating coverage for evenings, nights, weekends, and holidays.

Requirements

• Active RN license in the state where services are provided; the nurse may not work in states where they are not licensed. Any additional required state licensure must be obtained within 60 days.
• Valid state-issued driver’s license.
• One year of acute medical/surgical nursing experience.
• Basic Life Support (BLS) certification.
• For hires before 09-28-2026, CPR certification is required upon hire; for hires after 09-28-2026, BLS certification is required within 30 days of hire.
• Knowledge and skills to provide age-appropriate care to the patients served.
• Ability to demonstrate competence in home health and hospice standards of care, symptom management, and psychosocial and spiritual aspects of care.
• Excellent interpersonal skills and ability to communicate, read, and write in English.
• Ability to function well, manage time effectively, and prioritize a busy schedule.
• Good organizational skills.
• Ability to function effectively, autonomously, and independently in a home care setting.
• Ability to perform the listed physical activities, including standing, walking, sitting, handling objects or controls, reaching, climbing stairs, balancing, stooping, kneeling, crouching or crawling, and communicating through speech and hearing.
• Ability to regularly lift and/or move 25 pounds and occasionally lift and/or move up to 100 pounds.
• Ability to exchange accurate information by phone, email, and/or in person; the role frequently communicates internally and externally.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Specialty nursing certifications.
• Three years of acute nursing experience, including medical/surgical, oncology, hospice, or home health.
• Experience with IV therapy and complex wound care.

Responsibilities

• Assess patients’ physical and psychosocial needs in a sensitive, caring manner, following nursing standards and agency policies; provide ongoing interdisciplinary assessment.
• Assess patient and family learning needs, styles, and limitations, and adapt information delivery accordingly.
• Recognize and respect patients’ and caregivers’ cultural beliefs regarding death and dying.
• Establish realistic goals and develop treatment plans with patients, families, and the health care team.
• Identify suspected abuse or neglect and follow the applicable reporting process.
• Adapt to new or unusual situations and use Security when needed for potentially unsafe situations.
• Collaborate with patients, families, health care providers, and community resources on care planning and discharge.
• Evaluate patient and family progress and goal achievement; keep the Clinical Manager informed and justify continuation or termination of services.
• Document patient data, activities, and communications accurately and promptly in the patient record using the computer system, meeting applicable legal, certification, payer, and agency requirements.
• Complete physicians’ orders, levels of care, and OASIS documentation for assigned patients; consistently reconcile medications with patients and physicians.
• Follow safety guidelines and procedures, including ergonomics, fire and personal safety, proper body mechanics, and patient and material handling.
• Respond appropriately to emergencies and follow safety and security protocols, including stabilizing techniques.
• Support patients and families coping with emotional stress.
• Manage the assigned caseload within the team model; establish a daily work plan based on patient and family priorities and area needs, and triage visits, messages, and calls according to urgency.
• Provide nursing coverage on a rotating basis for evenings, nights, weekends, and holidays.
• Use strong physical assessment and care-planning skills and maintain current knowledge of pharmacology, medication administration, and medication reconciliation.
• Coordinate care and discharge planning with team members during case conferences.
• Maintain working knowledge of third-party payers, regulatory bodies, and agency policies related to documentation and care.
• Communicate and collaborate regularly with all disciplines in the home care setting, or immediately when critical needs or crisis interventions arise.

Benefits

• Medical, dental, and vision benefits beginning on day one.
• 403(b) retirement plan with company match.
• Tuition reimbursement and continuing education support, including MedBridge access for PT continuing education and licensure or certification support.
• Career growth opportunities.
• Fleet car program.
• AVADE de-escalation and personal safety training.
• InvisaWear GPS-enabled safety devices.
• Escort services for staff safety in the field.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed